Practice Guidelines

Clinical Practice Guidelines for Recall and Maintenance

of Patients with Tooth-Borne and Implant-Borne
Dental Restorations
Avinash S. Bidra, BDS, MS, FACP; Diane M. Daubert, RDH, MS; Lily T. Garcia, DDS,
MS, FACP; Timothy F. Kosinski, MS, DDS, MAGD; Conrad A. Nenn, DDS; John A.
Olsen, DDS, MAGD, DICOI; Jeffrey A. Platt, DDS, MS; Susan S. Wingrove, RDH, BS;
Nancy Deal Chandler, RHIA, CAE, CFRE; Donald A. Curtis, DMD, FACP

Abstract
Purpose: To provide guidelines for patient recall regimen, professional maintenance regimen, and
at-home maintenance regimen for patients with tooth- and implant-borne removable and fixed res-
torations.
Methods: The American College of Prosthodontists (ACP) convened a scientific panel of experts
appointed by the ACP, American Dental Association (ADA), Academy of General Dentistry (AGD),
and American Dental Hygienists Association (ADHA) who critically evaluated and debated recently
published findings from 2 systematic reviews on this topic. The major outcomes and consequenc-
es considered during formulation of the clinical practice guidelines (CPGs) were risk for failure of
tooth- and implant-borne restorations. The panel conducted a round table discussion of the proposed
guidelines, which were debated in detail. Feedback was used to supplement and refine the proposed
guidelines, and consensus was attained.
Results: A set of CPGs was developed for tooth-borne restorations and implant-borne restorations.
Each CPG comprised of 1) patient recall; 2) professional maintenance, and 3) at-home maintenance.
For tooth-borne restorations, the professional maintenance and at-home maintenance CPGs were
subdivided for removable and fixed restorations. For implant-borne restorations, the professional
maintenance CPGs were subdivided for removable and fixed restorations and further divided into
biological maintenance and mechanical maintenance for each type of restoration. The at-home main-
tenance CPGs were subdivided for removable and fixed restorations.
Conclusion: The clinical practice guidelines presented in this document were initially developed us-
ing the 2 systematic reviews. Additional guidelines were developed using expert opinion and consen-
sus, which included discussion of the best clinical practices, clinical feasibility and risk-benefit ratio
to the patient. To the authors’ knowledge, these are the first CPGs addressing patient recall regimen,
professional maintenance regimen, and at-home maintenance regimen for patients with tooth-borne
and implant-borne restorations. This document serves as a baseline with the expectation of future
modifications when additional evidence becomes available.
Keywords: clinical practice guidelines, tooth-borne, implant-borne, patient recall, maintenance
This review was funded in part by an unrestricted educational grant to the American College of
Prosthodontists Education Foundation from the Colgate-Palmolive Company.
Guidelines Promulgated and Published by the American College of Prosthodontists (ACP) in the Jour-
nal of Prosthodontics. Copyright 2016. All rights reserved. Reproduced under agreement with ACP.

Introduction
Clinical practice guidelines (CPG) are intended to
provide clinicians with guidance in diagnosis, treat-
ment planning, and clinical decision-making.1 CPGs
have been shown to improve patient care process-
es and clinical outcomes, and to better identify
and limit treatment risks.1-4 Although empirically
developed CPGs have been used in medicine for
hundreds of years, in the 1990s systematic ap-
proaches were advanced and advocated for CPGs.
In an extensive systematic review of 59 published
60 The Journal
CPGs in medicine, Grimshaw and Russell4 showed
that explicit CPGs improved clinical practice when
introduced in the context of rigorous evaluations.
In dentistry, a few oft-cited CPGs include the use
of antibiotic prophylaxis before dental procedures
to prevent endocarditis in certain cardiac patients,5
the use of prophylactic antibiotics prior to dental
procedures in patients with prosthetic joints,6 an-
tibiotic prophylaxis for dental patients at risk for
infection,7 oral health care for the pregnant ado-
of Dental Hygiene Vol. 90 • No. 1 • February 2016
lescent,8 guidelines for the care and maintenance
of complete dentures,9 management of patients
with medication-related osteonecrosis of the jaws
(MRONJ)10 and many others.11 The United States
maintains a national registry in the National
Guideline Clearinghouse for evidence-based clini-
cal practice guidelines, which are submitted and
endorsed by various medical and professional or-
ganizations.11 It is important to note that unlike
traditional CPGs based on empiricism or medical
authority, modern CPGs involve a systematic and
transparent process for scrutiny of scientific evi-
dence, and recommendations are made with the
intent that they will be updated and modified as
scientific evidence becomes available.1-4 Despite
this, recommendations made in CPGs are not al-
ways supported by scientific evidence. This is be-
cause many empirical procedures and treatments
that yield favorable outcomes do not necessarily
have scientific evidence at the present time.12
Patients seeking prosthodontic care often pres-
ent with significant previous dental treatment, a
complex etiology of factors contributing to the
loss of teeth, loss of tooth structure, and equal-
ly complex treatment needs to restore function
and esthetics. Treatment plans to address patient
needs using tooth- or implant-borne restorations
require careful diagnosis, risk assessment, treat-
ment planning, meticulous execution of care, and
a long-term partnership with the patient and treat-
ment team to maintain an enduring result. Giv-
en the resources required to treat patients with
complex dental needs, an appropriate patient re-
call regimen, professional maintenance regimen,
and at-home maintenance regimen are paramount
for long-term success.13,14 Furthermore, it is likely
that the professional and at-home maintenance
protocols in healthy adult patients with tooth- and
implant-borne restorations may be significantly
different when compared to patients with no resto-
rations, or patients with acute or chronic oral and
systemic diseases. For tooth-borne restorations,
guidelines on the options and relative merits of
professional and at-home maintenance protocols
to predictably achieve stable results are lacking.13
Current guidelines for the maintenance of implant
restorations are poorly defined and often based on
empiricism or traditional protocols for patients with
natural dentition rather than what is most suitable
for maintenance of implant restorations and sup-
porting tissues.14 Therefore, professional and at-
home maintenance guidelines are necessary for
patients with tooth- and implant-borne removable
and fixed restorations to improve the health of
supporting tissues, limit disease processes such as
caries, periodontitis, or peri-implant disease, and
improve the expected longevity of restorations as
well as the supporting teeth and implants them-
selves. Guidelines are needed to provide direction
Vol. 90 • No. 1 • February 2016 The Journal
for the dental health care provider with the goal of
improved clinical outcomes for the patient.
Patients with complex tooth- and implant-borne
restorations require a lifelong professional recall
regimen to provide biological and mechanical main-
tenance customized for each patient. Therefore,
the purpose of this CPG document is to provide: 1)
guidelines for patient recall regimen, professional
maintenance regimen, and at-home maintenance
regimen for patients with tooth-borne restora-
tions and 2) guidelines for patient recall regimen,
professional maintenance regimen, and at-home
maintenance regimen for patients with implant-
borne restorations. The target populations of this
CPG are patients with tooth- and implant-borne re-
movable and fixed restorations. The intended us-
ers of the presented CPGs are: general dentists,
dental hygienists, prosthodontists and other den-
tal specialists, dental health care providers, allied
health personnel, nurses, social workers, students,
patients, medical and dental insurance carriers,
and public health departments.
Methods and Materials
To the authors’ knowledge, this is the first CPG
addressing patient recall regimen, professional
maintenance regimen, and at-home maintenance
regimen for patients with tooth- and implant-borne
restorations and serves as a baseline for future
modifications and versions based on future sci-
entific evidence. Two separate systematic reviews
of the literature were conducted to evaluate the
recall and maintenance regimens for tooth- and
implant-borne restorations.13,14 The systematic re-
view on tooth-borne restorations included articles
published from January 1, 1999 to December 31,
2014. The systematic review on implant-borne res-
torations included articles published from January
1, 2004 to December 31, 2014. The detailed meth-
odology for the search processes are described in
the respective systematic review articles.13,14 For
tooth-borne restorations, 16 studies were identi-
fied in the systematic review that reported data on
a combined 3569 patients. Of these, nine were ran-
domized controlled clinical trials (RCT), and seven
were observational studies. For implant-borne res-
torations, 20 studies were identified, reporting on
1088 patients. Of these, eleven were RCTs, and
nine were observational studies. Results from all
of these studies were scrutinized, tabulated, and
analyzed to formulate conclusions and then create
the CPGs.
A scientific panel comprised of experts appointed
by the American College of Prosthodontists (ACP),
American Dental Association (ADA), Academy of
General Dentistry (AGD), and American Dental
Hygienists Association (ADHA) critically evaluat-
of Dental Hygiene 61
ed and debated the published evidence from two
systematic reviews on this topic. A rating scheme
for strength of recommendation as described by
Shekelle et al1 was used as it was most applica-
ble to this topic and is widely used and validated
in the medical literature (Tables I, II). The ma-
jor outcomes and consequences considered during
formulation of these CPGs were: 1) risk for fail-
ure of tooth-borne restorations and 2) risk for fail-
ure of implant-borne restorations. Thereafter, the
members of the task force conducted a roundtable
peer review/evaluation discussion of the proposed
guidelines, and the guidelines were debated in de-
tail. These inputs were used to supplement and
refine the proposed guidelines, and consensus was
attained for the various guidelines presented.
Results
Patients with tooth- and implant-borne restora-
tions require a lifelong professional recall regimen
to provide biological and mechanical maintenance,
customized for each patient. Therefore, a set of
CPGs was created for each type of restoration com-
prising: 1) patient recall; 2) professional mainte-
nance, and 3) at-home maintenance. The CPGs
are presented in Table III for tooth-borne resto-
rations15-30 and Table IV for implant-borne resto-
rations.31-50 For tooth-borne restorations, the pro-
fessional maintenance and at-home maintenance
CPGs were subdivided for removable and fixed
restorations. For implant-borne restorations, the
professional maintenance CPGs were sub-divided
for removable and fixed restorations and further
divided into biological maintenance and mechani-
cal maintenance for each type of restoration. The
at-home maintenance CPGs were subdivided for
removable and fixed restorations. The strength of
evidence and subsequent recommendation that is
presently available was applied for each guideline.
When a guideline comprised multiple aspects, then
multiple strengths of available recommendations in
descending order were applied. Additionally, when
multiple strengths of recommendation were avail-
able for a specific guideline, they were all applied
accordingly.
Discussion
The scientific panel considered the potential
benefits, harms, contraindications, and scope of
these guidelines. The potential benefits for these
guidelines include: 1) improved oral health and
longevity of natural teeth, tooth-borne, and im-
plant-borne restorations and 2) improved oral
health related quality of life. The potential harms
considered were 1) increased short-term cost to
patients to adhere to recall regimen, professional
maintenance regimen, and at-home maintenance
regimen and 2) adverse effects related to any of
62 The Journal
Table I: Levels and Category of Evidence as
Described by Shekelle et al1
Level Category of Evidence
Evidence from systematic review of ran-
Ia
domized controlled trials
Evidence from at least one randomized
Ib
controlled trial
Evidence from at least one controlled
IIa
study without randomization
Evidence from at least one other type of
quasi-experimental study, such as time
IIb
series analysis or studies in which the unit
of analysis is not the individual
Evidence from non-experimental descrip-
tive studies, such as comparative studies,
III
correlation studies, cohort studies, and
case- control studies
Evidence from expert committee reports or
IV opinions or clinical experience of respected
authorities or both
Table II: Rating Scheme for the Strength of
Recommendation as Described by Shekelle
et al1
Classification Strength of recommendation
Directly based on category I evi-
A
dence
Directly based on category II evi-
B dence or extrapolated from cat-
egory I evidence
Directly based on category III evi-
C dence or extrapolated from cat-
egory I or II evidence
Directly based on category IV evi-
D dence or extrapolated from cat-
egory I, II, or III evidence
the professionally used oral topical agents or at-
home oral topical agents and oral hygiene aids.
The contraindications to these guidelines include
allergies or adverse effects related to any of the
professionally used oral topical agents or at-home
oral topical agents.
A potential source of bias considered during de-
velopment of the CPGs was that authors of the sys-
tematic reviews also served as panel members for
the CPG.51,52 To minimize this potential bias, efforts
were made during the scientific panel meetings to
debate and justify each guideline in an open and
transparent format. Financial and organizational
conflicts of interests were not identified. Strength
of evidence was debated for every guideline. Thus,
the effect of “groupthink” may not be a source of
of Dental Hygiene Vol. 90 • No. 1 • February 2016
Table III: Clinical Practice Guidelines for Recall and Maintenance of Patients with Tooth-
Borne Dental Restorations
Strength of
Number Topic Guideline Recommendation
Patients with tooth-borne restorations (fixed or removable)
should be advised to obtain a dental professional examination at D
least every 6 months as a lifelong regimen.
1. Patient recall Patients categorized by the dentist as higher risk based on age,
ability to perform oral self care, biological or mechanical com-
plications of natural teeth or tooth-borne restorations should be D
advised to obtain a dental professional examination more often
than every 6 months, depending upon the clinical situation.
Professional maintenance for patients with tooth-borne remov-
able restorations should include an extraoral and intraoral health
and dental examination, oral hygiene instructions for existing A, C, D
natural teeth and any restorations, oral hygiene intervention
(cleaning of natural teeth and restorations), and use of oral topi-
cal agents as deemed clinically necessary.
Professional main-
tenance: Tooth- Professional maintenance of the partial removable dental pros-
borne removable theses should include hygiene instructions, detailed examination
2A.
restorations (partial of the prosthesis, prosthetic components and patient education
removable dental about any foreseeable problems that could impair optimal func- D
prostheses) tion with the restoration. The partial removable dental prosthesis
should be professionally cleaned extraorally using professionally
accepted mechanical and chemical methods.
Professionals should recommend and/or prescribe appropriate
oral topical agents and oral hygiene aids suitable for the patient’s D
at-home maintenance needs.
Professional maintenance for patients with tooth-borne fixed
restorations should include an extraoral and intraoral health and
dental examination, oral hygiene instructions for natural teeth A, C, D
and the fixed restorations, oral hygiene intervention (cleaning of
natural teeth and restorations), and use of oral topical agents as
Professional main- deemed clinically necessary.
tenance: Tooth-
borne fixed restora- Professionals should recommend and/or prescribe appropriate
tions (intracoronal oral topical agents and oral hygiene aids suitable for the patient’s D
restorations, ex- at-home maintenance needs.
2B. tracoronal resto- When clinical signs indicate the need for an occlusal device, pro-
rations, veneers, fessionals should educate the patient and fabricate an occlusal D
single crowns, and device to protect the tooth-borne fixed restorations.
partial fixed dental
prostheses) Professional maintenance of the occlusal device should include
hygiene instructions, detailed examination of the occlusal device,
and patient education about any foreseeable problems that could D
impair optimal function with the occlusal device. The occlusal
device should be professionally cleaned extraorally, using profes-
sionally accepted mechanical and chemical methods.
Note: Guidelines 2A, 2B, 3A and 3B are supported by references 15 through 30

bias in this baseline CPG document. Conversely,
having the same author group to draft the CPGs
may be viewed as a strength of this document,
due to the profound insight obtained by the author
group during the systematic review process.
Most of the guidelines in this document are
graded as category D for strength of recommenda-
tion, but it is anticipated that the strength of rec-
ommendation would be higher in the future. Using
Shekelle’s method1 for grading the strength of rec-
ommendation allowed incorporation and delinea-
tion of various types of evidence, including expert
Vol. 90 • No. 1 • February 2016 The Journal
opinion/consensus, into four categories, while for-
mulating these guidelines. Additionally, it allowed
extrapolation of higher categories of evidence to
lower categories and provided more freedom in
designation of an article to a specific category. The
authors considered other widely popular alterna-
tives such as Grading of Recommendations As-
sessment, Development and Evaluation (GRADE)
method,53 and the Strength of Recommendation
Taxonomy (SORT) method.54 However, these al-
ternatives were less applicable to the topic of this
baseline CPG. The GRADE method divides the ex-
pression of evidence into only two categories, weak
of Dental Hygiene 63
Table III: Clinical Practice Guidelines for Recall and Maintenance of Patients with Tooth-
Borne Dental Restorations (continued)
Strength of
Number Topic Guideline Recommendation
Patients with tooth-borne removable restorations should be
educated about brushing existing natural teeth and restorations
twice daily, and the use of oral hygiene aids such as dental floss, C, D
water flossers, air flossers, interdental cleaners, and electric
toothbrushes.
Patients with tooth-borne removable restorations should be edu-
cated about cleaning their prosthesis at least twice daily using a
At-home mainte- D
soft brush and the professional recommended denture-cleaning
nance: Tooth-borne agent.
removable res-
3A. Patients with multiple and complex restorations on existing teeth
torations (partial
removable dental supporting or surrounding the removable restoration should be
prostheses) advised to use oral topical agents such as toothpaste containing A, C, D
5000 ppm fluoride or toothpaste with 0.3% triclosan, and to add
supplemental short-term use of chlorhexidine gluconate when
indicated.
Patients with tooth-borne removable restorations should be
advised to remove the restoration out of the mouth during sleep. D
The removed prosthesis should be stored in a prescribed clean-
ing solution.
Patients with tooth-borne fixed restorations should be educated
about brushing twice daily, and the use of oral hygiene aids such A, D
as dental floss, water flossers, air flossers, interdental cleaners,
and electric toothbrushes.
At-home mainte-
nance: Tooth-borne Patients with multiple and complex restorations on existing teeth
fixed restorations should be advised to use oral topical agents such as toothpaste
(intracoronal resto- containing 5000 ppm fluoride or toothpaste with 0.3% triclosan, A, C, D
rations, extracoro- and to add supplemental short-term use of chlorhexidine gluco-
3B. nate when indicated.
nal restorations,
veneers, single Patients prescribed with occlusal devices should be advised to
crowns, and partial D
wear the occlusal device during sleep.
fixed dental pros-
theses) Patients prescribed with occlusal devices should be educated
about cleaning their occlusal device before and after use, with
a soft brush and the prescribed cleaning agent. Patients should D
also be educated about proper methods for storage of the oc-
clusal device when not in use.
Note: Guidelines 2A, 2B, 3A and 3B are supported by references 15 through 30

or strong, which was not appropriate for this base-
line CPG.53 The SORT method divides the strength
of recommendation into three categories (A, B and
C) but does not allow extrapolation of higher cat-
egories of evidence to lower categories.54
to improve patient care protocols, but is not in-
tended as a standard of care. The outlined CPGs
should be supplemented with professional judg-
ment and consideration of the unique needs and
preferences of each patient.

This document is intended for healthy adult pa-

tients with tooth- or implant-borne restorations.
Management of patients with mixed restorations
(tooth- and implant-borne removable or fixed res-
torations) in one or both jaws should encompass
both sets of proposed guidelines, appropriate to
the clinical situation. Management of patients with
conditions such as bruxism, xerostomia, periodon-
tal disease, peri-implant disease, or other condi-
tions are outside the scope of these CPGs; howev-
er, the recall and maintenance regimen guidelines
made in this document would likely be helpful to
these patients. This baseline document is intended
64 The Journal
Conclusion
This document provides clinical practice guide-
lines for patient recall regimen, professional
maintenance regimen, and at-home maintenance
regimen for patients with tooth-borne and implant-
borne restorations. The various guidelines were
made using the best level of evidence whenever
available. Guidelines made using expert opinion/
consensus included the best possible analysis of
best clinical practices, clinical feasibility, and risk-
benefit ratio for patients. A scientific panel ap-
of Dental Hygiene Vol. 90 • No. 1 • February 2016
Table IV: Clinical Practice Guidelines for Recall and Maintenance of Patients with Implant-
Borne Dental Restorations

Number Topic Guideline Strength of

Recommendation
Patients with implant-borne restorations (fixed or removable)
should be advised to obtain a dental professional examination D
visit at least every 6 months as a lifelong regimen.
Patients categorized by the dentist as higher risk based on age,
1. Patient recall ability to perform oral self care, biological or mechanical compli-
cations of remaining natural teeth, tooth-borne restorations or D
implant-borne restorations should be advised to obtain a dental
professional examination more often than every 6 months, de-
pending upon the clinical situation.
Professional biological maintenance for patients with implant-
borne removable restorations should include an extraoral and
intraoral health and dental examination, oral hygiene instruc- A, C, D
tions, hygiene instructions for the prostheses and oral hygiene
intervention (cleaning of any natural teeth, tooth-borne restora-
Professional main- tions, implant-borne restorations, or implant abutments).
tenance (Biologi- Professionals should use chlorhexidine gluconate as the oral topi-
cal): Implant-borne cal agent of choice when antimicrobial effect is needed clinically. A, C
removable resto-
rations (implant- Professionals should use cleaning instruments compatible with
2A. supported partial the type and material of the implants, abutments and restora- A, C, D
removable dental tions, and powered instruments such as the glycine powder air
prostheses and polishing system.
implant-supported
overdenture pros- Implant-supported partial removable dental prostheses and
theses) implant-supported overdenture prostheses should be profession- D
ally cleaned extraorally using professionally accepted mechanical
and chemical cleaning methods.
Professionals should recommend and/or prescribe appropriate
oral topical agents and oral hygiene aids suitable for the patient’s A, C, D
at-home maintenance needs.
Professional main- Professional mechanical maintenance for patients with implant-
tenance (Mechani- borne removable restorations should include a detailed examina-
cal): Implant-borne tion of the prosthesis, intra and extraoral prosthetic components, C, D
removable resto- and patient education of foreseeable problems that could impair
rations (implant- optimal function of the restoration.
2B. supported partial
removable dental
prostheses and Professionals should recommend and perform adjustment, re-
implant-supported pair, replacement, or remake of any or all parts of the prosthesis C, D
overdenture pros- and prosthetic components that could compromise function.
theses)
Professional biological maintenance for patients with implant-
borne fixed restorations should include an extraoral and intraoral
health and dental examination, oral hygiene instructions, and oral A, C, D
hygiene intervention (cleaning of any natural teeth, tooth-borne
restorations, implant-borne restorations, or implant abutments).
Professional main- Professionals should use chlorhexidine gluconate as the oral topi-
tenance (Biologi- cal agent of choice when antimicrobial effect is needed clinically. A, C
cal): Implant-borne
fixed restorations Professionals should use cleaning instruments compatible with
(implant-supported the type and material of the implants, abutments, and restora- A, C, D
2C. single crowns, tions, and powered instruments such as the glycine powder air
partial fixed dental polishing system.
prostheses and
implant-supported In patients with implant-supported fixed prostheses, the deci-
complete arch fixed sion to remove the prosthesis for biological maintenance should
prostheses) be based on the patient’s demonstrated inability to perform D
adequate oral hygiene. The prosthesis contours should be reas-
sessed to facilitate at-home maintenance.
Professionals should consider using new prosthetic screws when
an implant-borne restoration is removed and replaced for profes- D
sional biological maintenance.
Guidelines 2A, 2B, 2C, 2D, 3A and 3B are supported by references 31 through 50

Vol. 90 • No. 1 • February 2016 The Journal of Dental Hygiene 65

Table IV: Clinical Practice Guidelines for Recall and Maintenance of Patients with Implant-
Borne Dental Restorations (continued)

Number Topic Guideline Strength of

Recommendation
Professional mechanical maintenance for patients with implant-
borne fixed restorations should include a detailed examination C, D
of the prosthesis, prosthetic components, and patient education
about any foreseeable problems that could compromise function.
Professionals should recommend and perform adjustment, repair,
replacement, or remake of any or all parts of the prosthesis and C, D
prosthetic components that could impair patient’s optimal function.
Professionals should consider using new prosthetic screws when
Professional main- an implant-borne restoration is removed and replaced for profes- D
tenance (Mechani- sional mechanical maintenance.
cal): Implant-borne When clinical signs indicate the need for an occlusal device, pro-
fixed restorations fessionals should educate the patient and fabricate an occlusal D
(implant-supported device to protect implant-borne fixed restorations.
2D. single crowns,
partial fixed dental Professional maintenance of the occlusal device should include
prostheses, and hygiene instructions, detailed examination of the occlusal device,
implant-supported and patient education about any foreseeable problems that could
complete arch fixed impair optimal function with the occlusal device. The occlusal D
prostheses) device should be professionally cleaned extraorally using profes-
sionally accepted mechanical and chemical methods.
Patients with multiple and complex restorations on existing teeth
should be advised to use oral topical agents such as toothpaste
containing 5000 ppm fluoride or toothpaste with 0.3% triclosan, A, C, D
and to add supplemental short-term use of chlorhexidine gluco-
nate when indicated.
Patients prescribed with occlusal devices should be educated to D
wear the occlusal device during sleep.
Patients with implant-supported partial removable dental pros-
theses should be educated about brushing existing natural
teeth and restorations twice daily, and the use of oral hygiene C, D
aids such as dental floss, water flossers, air flossers, interdental
At-home mainte- cleaners, and electric toothbrushes.
nance: Implant-
borne remov- Patients with implant-borne removable restorations should be
able restorations advised to clean their intraoral implant components at least twice D
(implant-supported daily, using a soft brush and the professionally recommended
3A. partial removable oral topical agent.
dental prostheses, Patients with implant-borne removable restorations should be
and implant-sup- advised to clean their prosthesis at least twice daily using a soft D
ported overdenture brush with a professional recommended denture-cleaning agent.
prostheses)
Patients with implant-borne partial or complete removable resto-
rations should be advised to remove the restoration while sleep- D
ing. The removed prosthesis should be stored in a prescribed
cleaning solution.
Patients with implant-borne fixed restorations should be edu-
cated about brushing twice daily, and the use of oral hygiene C, D
aids such as dental floss, water flossers, air flossers, interdental
At-home mainte- cleaners and electric toothbrushes.
nance: Implant-
borne fixed Patients with multiple and complex implant-borne fixed resto-
restorations rations, should be advised to use oral topical agents such as A, C, D
(implant-supported toothpaste containing 0.3% triclosan and to add supplemental
3B. single crowns, short-term use of chlorhexidine gluconate when indicated.
partial fixed dental Patients prescribed with occlusal devices should be advised to
prostheses and wear the occlusal device during sleep. D
implant-supported
complete arch fixed Patients prescribed with occlusal devices should be educated
prostheses) about cleaning their occlusal device before and after use, with
a soft brush and the prescribed cleaning agent. Patients should D
also be educated about proper methods for storage of the oc-
clusal device when not in use.
Guidelines 2A, 2B, 2C, 2D, 3A and 3B are supported by references 31 through 50

66 The Journal of Dental Hygiene Vol. 90 • No. 1 • February 2016

pointed by the American College of Prosthodontists
(ACP), American Dental Association (ADA), Acad-
emy of General Dentistry (AGD), and American
Dental Hygienists Association (ADHA) developed
and approved the CPGs. This document serves as
a baseline with the expectation of future modifica-
tions to reflect best clinical practices and when ad-
ditional evidence becomes available.
Avinash S. Bidra, BDS, MS, FACP, Department of
Reconstructive Sciences, University of Connecticut
Health Center. Diane M. Daubert, RDH, MS, De-
partment of Periodontics, University of Washington
School of Dentistry. Lily T. Garcia, DDS, MS, FACP,
Office of the Dean, University of Iowa College of
Dentistry & Dental Clinics. Timothy F. Kosinski,
References
1. Shekelle PG, Woolf SH, Eccles M, et al. Clini-
cal guidelines: developing guidelines. Brit Med J.
1999;318:593-596.
2. Fervers B, Burgers JS, Haugh MC, et al. Predic-
tors of high quality clinical practice guidelines:
examples in oncology. Int J Qual Health Care.
2005;17:123-132.
3. Burgers JS, Grol R, Klazinga NS, et al. For the
AGREE Collaboration: Towards evidence-based
clinical practice: an international survey of 18 clin-
ical guideline programs. Int J Qual Health Care.
2003;15:31-45.
4. Grimshaw JM, Russell IT. Effect of clinical guide-
lines on medical practice: a systematic review of
rigorous evaluations. Lancet. 1993;342:1317-
1322.
5. Wilson W, Taubert KA, Gewitz M, et al. Preven-
tion of infective endocarditis: guidelines from the
American Heart Association: a guideline from the
American Heart Association Rheumatic Fever,
Endocarditis and Kawasaki Disease Committee,
Council on Cardiovascular Disease in the Young,
and the Council on Clinical Cardiology, Council
on Cardiovascular Surgery and Anesthesia, and
the Quality of Care and Outcomes Research In-
terdisciplinary Working Group. J Am Dent Assoc.
2008;139 Suppl:3S-24S.
6. Sollecito TP, Abt E, Lockhart PB, et al. The use of
prophylactic antibiotics prior to dental procedures
in patients with prosthetic joints: Evidence-based
clinical practice guideline for dental practitioners-
-a report of the American Dental Association
Council on Scientific Affairs. J Am Dent Assoc.
2015;146:11-16.e8.
Vol. 90 • No. 1 • February 2016 The Journal
MS, DDS, MAGD, Department of Restorative Den-
tistry, University of Detroit Mercy School of Den-
tistry. Conrad A. Nenn, DDS, Department of Gen-
eral Dental Sciences, Marquette University School
of Dentistry. John A. Olsen, DDS, MAGD, DICOI,
Private Practice, Franklin, Wisc. Jeffrey A. Platt,
DDS, MS, Department of Biomedical and Applied
Sciences, Division of Dental Biomaterials, Indiana
University School of Dentistry. Susan S. Wingrove,
RDH, BS, Private Practice Hygienist, Regenera-
tion Research, Missoula, Mont. Nancy Deal Chan-
dler, RHIA, CAE, CFRE, Executive Director, Ameri-
can College of Prosthodontists and ACP Education
Foundation. Donald A. Curtis, DMD, FACP, Depart-
ment of Preventive & Restorative Dental Sciences,
UCSF School of Dentistry.
7. American Academy on Pediatric Dentistry Clinical
Affairs Committee; American Academy on Pediat-
ric Dentistry Council on Clinical Affairs. Guideline
on antibiotic prophylaxis for dental patients at risk
for infection. Pediatr Dent. 2008-2009;30:215-
218.
8. American Academy of Pediatric Dentistry, Council
on Clinical Affairs, Committee on the Adolescent.
Guideline on oral health care for the pregnant ad-
olescent. Pediatr Dent. 2012;34:153-159.
9. Felton D, Cooper L, Duqum I, et al. Evidence-based
guidelines for the care and maintenance of com-
plete dentures: a publication of the American Col-
lege of Prosthodontists. J Prosthodont. 2011;20
Suppl 1:S1-S12.
10. Ruggiero SL, Dodson TB, Fantasia J, et al. Ameri-
can Association of Oral and Maxillofacial Surgeons
position paper on medication-related osteone-
crosis of the jaw--2014 update. J Oral Maxillofac
Surg. 2014;72:1938-1956.
11. Agency for Healthcare Research and Quality. Na-
tional Guideline Clearing House. U.S. Department
of Health and Human Services. 2015.
12. Bidra AS. Evidence-based prosthodontics: funda-
mental considerations, limitations and guidelines.
Dent Clin North Am. 2014;58:1-17.
13. Bidra AS, Daubert DM, Garcia LT, et al. A system-
atic review of recall regimen and maintenance
regimen of patients with dental restorations-
Part 1: Tooth-borne restorations. J Prosthodont.
2016;25:S2-S15.
of Dental Hygiene 67
14. Bidra AS, Daubert DM, Garcia LT, et al. A system-
atic review of recall regimen and maintenance
regimen of patients with dental restorations- Part
2: Implant-borne restorations J Prosthodont.
2016;25:S16-S31.
15. Ercalik-Yalcinkaya S, Ozcan M. Association be-
tween oral mucosal lesions and hygiene habits in
a population of removable prosthesis wearers. J
Prosthodont. 2015;24:271-278.
16. Morino T, Ookawa K, Haruta N, et al. Effects of
professional oral health care on elderly: Random-
ized trial. Int J Dent Hyg. 2014;12:291-297.
17. Ekstrand KR, Poulsen JE, Hede B, et al. A random-
ized clinical trial of the anti-caries efficacy of 5,000
compared to 1,450 ppm fluoridated toothpaste
on root caries lesions in elderly disabled nursing
home residents. Caries Res. 2013;47:391-398.
18. Fardal Ø, Grytten J. A comparison of teeth and
implants during maintenance therapy in terms of
the number of disease-free years and costs -- an
in vivo internal control study. J Clin Periodontol.
2013;40:645-651.
19. De Visschere L, Schols J, van der Putten GJ, et
al. Effect evaluation of a supervised versus non-
supervised implementation of an oral health
care guideline in nursing homes: A cluster ran-
domised controlled clinical trial. Gerodontology.
2012;29:e96-106.
20. López-Jornet P, Plana-Ramon E, Leston JS, et
al. Short-term side effects of 0.2% alcohol-free
chlorhexidine mouthrinse in geriatric patients:
A randomized, double-blind, placebo-controlled
study. Gerodontology. 2012;29:292-298.
21. van der Putten GJ, Mulder J, de Baat C, et al. Ef-
fectiveness of supervised implementation of an
oral health care guideline in care homes; a single-
blinded cluster randomized controlled trial. Clin
Oral Investig. 2013;17:1143-1153.
22. Wolfart S, Weyer N, Kern M. Patient attendance
in a recall program after prosthodontic reha-
bilitation: A 5-year follow-up. Int J Prosthodont.
2012;25:491-496.
23. Zenthöfer A, Dieke R, Dieke A, et al. Improv-
ing oral hygiene in the long-term care of the el-
derly--a RCT. Community Dent Oral Epidemiol.
2013;41:261-268.
24. Ababnaeh KT, Al-Omari M, Alawneh TN. The ef-
fect of dental restoration type and material
on periodontal health. Oral Health Prev Dent.
2011;9:395-403.
68 The Journal of
25. Nassar CA, Serraglio AP, Balotin A, et al. Effect
of maintenance therapy with or without the use
of chlorhexidine in teeth restored with composite
resin in patients with diabetes mellitus. Gen Dent.
2011;59:e149-152.
26. Ikai H, Kanno T, Kimura K, et al. A retrospective
study of fixed dental prostheses without regular
maintenance. J Prosthodont Res. 2010;54:173-
178.
27. Ortolan SM, Viskić J, Stefancić S, et al. Oral hy-
giene and gingival health in patients with fixed
prosthodontic appliances--a 12-month follow-up.
Coll Antropol. 2012;36:213-220.
28. Vered Y, Zini A, Mann J, et al. Comparison of a
dentifrice containing 0.243% sodium fluoride,
0.3% triclosan, and 2.0% copolymer in a silica
base, and a dentifrice containing 0.243% sodium
fluoride in a silica base: A three-year clinical trial
of root caries and dental crowns among adults. J
Clin Dent. 2009;20:62-65.
29. Ribeiro DG, Pavarina AC, Giampaolo ET, et al. Ef-
fect of oral hygiene education and motivation on
removable partial denture wearers: Longitudinal
study. Gerodontology. 2009;26:150-156.
30. Zoellner A, Heuermann M, Weber HP, et al. Sec-
ondary caries in crowned teeth:Correlation of
clinical and radiographic findings. J Prosthet Dent.
2002;88:314-319.
31. Magnuson B, Harsono M, Stark PC, et al. Compari-
son of the effect of two interdental cleaning de-
vices around implants on the reduction of bleed-
ing: A 30-day randomized clinical trial. Compend
Contin Educ Dent. 2013;34 Spec No 8:2-7.
32. Morawiec T, Dziedzic A, Niedzielska I, et al. The
biological activity of propolis-containing tooth-
paste on oral health environment in patients who
underwent implant-supported prosthodontic reha-
bilitation. Evid Based Complement Alternat Med.
2013;2013:704947.
33. Mussano F, Rovasio S, Schierano G, et al. The effect
of glycine-powder airflow and hand instrumenta-
tion on peri-implant soft tissues: A split-mouth pi-
lot study. Int J Prosthodont. 2013;26:42-44.
34. Swierkot K, Brusius M, Leismann D, et al: Manual
versus sonic-powered toothbrushing for plaque
reduction in patients with dental implants: An ex-
planatory randomised controlled trial. Eur J Oral
Implantol. 2013;6:133-144.
Dental Hygiene Vol. 90 • No. 1 • February 2016
35. Zou D, Wu Y, Huang W, et al. A 3-year prospective
clinical study of telescopic crown, bar, and loca-
tor attachments for removable four implant-sup-
ported maxillary overdentures. Int J Prosthodont.
2013;26:566-573.
36. De Siena F, Francetti L, Corbella S, et al. Topical
application of 1% chlorhexidine gel versus 0.2%
mouthwash in the treatment of peri-implant mu-
cositis. An observational study. Int J Dent Hyg.
2013;11:41-47.
37. Chongcharoen N, Lulic M, Lang NP. Effectiveness
of different interdental brushes on cleaning the
interproximal surfaces of teeth and implants: A
randomized controlled, double-blind cross-over
study. Clin Oral Implants Res. 2012;23:635-640.
38. Costa FO, Takenaka-Martinez S, Cota LO, et al.
Peri-implant disease in subjects with and without
preventive maintenance: A 5-year follow-up. J
Clin Periodontol. 2012;39:173-181.
39. Fischer K, Stenberg T. Prospective 10-year co-
hort study based on a randomized, controlled
trial (RCT) on implant-supported full-arch max-
illary prostheses. Part II: Prosthetic outcomes
and maintenance. Clin Implant Dent Related Res.
2013;15:498-508.
40. Katsoulis J, Brunner A, Mericske-Stern R. Mainte-
nance of implant-supported maxillary prostheses:
A 2-year controlled clinical trial. Int J Oral Maxil-
lofac Implants. 2011;26:648-656.
41. Akça K, Cehreli MC, Uysal S. Marginal bone loss and
prosthetic maintenance of bar-retained implant-
supported overdentures: A prospective study. Int
J Oral Maxillofac Implants. 2010;25:137-145.
42. Corbella S, Del Fabbro M, Taschieri S, et al. Clinical
evaluation of an implant maintenance protocol for
the prevention of peri-implant diseases in patients
treated with immediately loaded full-arch rehabili-
tations. Int J Dent Hyg. 2011;9:216-222.
43. Rentsch-Kollar A, Huber S, Mericske-Stern R. Man-
dibular implant overdentures followed for over 10
years: Patient compliance and prosthetic mainte-
nance. Int J Prosthodont. 2010;23:91-98.
Vol. 90 • No. 1 • February 2016 The Journal of
44. Sreenivasan PK, Vered Y, Zini A, et al. A 6-month
study of the effects of 0.3% triclosan/copolymer
dentifrice on dental implants. J Clin Periodontol.
2011;38:33-42.
45. Thöne-Mühling M, Swierkot K, Nonnenmacher C,
et al. Comparison of two full-mouth approaches
in the treatment of peri-implant mucositis: A pilot
study. Clin Oral Implants Res. 2010;21:504-512.
46. Kleis WK, Kämmerer PW, Hartmann S, et al. A
comparison of three different attachment sys-
tems for mandibular two-implant overdentures:
One-year report. Clin Implant Dent Relat Res.
2010;12:209-218.
47. Paolantonio M, Perinetti G, D’Ercole S, et al. In-
ternal decontamination of dental implants: An in
vivo randomized microbiologic 6-month trial on
the effects of a chlorhexidine gel. J Periodontol.
2008;79:1419-1425.
48. Ramberg P, Lindhe J, Botticelli D, et al. The effect
of a triclosan dentifrice on mucositis in subjects
with dental implants: A six-month clinical study. J
Clin Dent. 2009;20:103-107.
49. Rasperini G, Pellegrini G, Cortella A, et al. The
safety and acceptability of an electric toothbrush
on peri-implant mucosa in patients with oral im-
plants in aesthetic areas: A prospective cohort
study. Eur J Oral Implantol. 2008;1:221-228.
50. Vandekerckhove B, Quirynen M, Warren PR, et al.
The safety and efficacy of a powered toothbrush
on soft tissues in patients with implant-supported
fixed prostheses. Clin Oral Investig. 2004;8:206-
210.
51. Guyatt G, Akl EA, Hirsh J, et al. The vexing prob-
lem of guidelines and conflict of interest: a poten-
tial solution. Ann Intern Med. 2010;152:738-741.
52. Guyatt GH, Schünemann HJ, Djulbegovic B, et al.
Guideline panels should not GRADE good practice
statements. J Clin Epidemiol. 2015;68:597-600.
53. Atkins D, Best D, Briss PA, et al. Grading quality of
evidence and strength of recommendations. BMJ.
2004;328:1490.
54. Ebell MH, Siwek J, Weiss BD, et al. Strength of rec-
ommendation taxonomy (SORT): a patient-cen-
tered approach to grading evidence in the medical
literature. Am Fam Physician. 2004;69:548-556.
Dental Hygiene 69
Copyright of Journal of Dental Hygiene is the property of American Dental Hygienists
Association and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.